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Heterotopic Bone Formation
Jeffrey S. Ross, MD
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KEY FACTS

  • Terminology

    • Imaging

      • Top Differential Diagnoses

        • Pathology

          • Clinical Issues

            • Diagnostic Checklist

              TERMINOLOGY

              • Abbreviations

                • Recombinant human bone morphogenetic protein 2 (rhBMP-2)
                • Total disc replacement (TDR)
                • Transforaminal lumbar interbody fusion (TLIF)
                • Posterior lumbar interbody fusion (PLIF)
              • Synonyms

                • Heterotopic ossification (HO)
                • Ectopic bone formation
                • Ectopic ossification
                • Extradiscal ossification
              • Definitions

                • Bone development in an abnormal location
                • Occurs in 3 main scenarios
                  • Osteobiologic (rhBMP-2) related
                  • Total disc replacement (TDR) related
                  • Anterior cervical discectomy and fusion (ACDF) adjacent segment related

              IMAGING

              • General Features

                • CT Findings

                  • MR Findings

                    • Imaging Recommendations

                      DIFFERENTIAL DIAGNOSIS

                        PATHOLOGY

                        • General Features

                          • Staging, Grading, & Classification

                            CLINICAL ISSUES

                            • Presentation

                              • Treatment

                                DIAGNOSTIC CHECKLIST

                                • Consider

                                  Selected References

                                  1. Simmonds MC et al: Safety and effectiveness of recombinant human bone morphogenetic protein-2 for spinal fusion: a meta-analysis of individual-participant data. Ann Intern Med. 158(12):877-89, 2013
                                  2. Singh K et al: Clinical sequelae after rhBMP-2 use in a minimally invasive transforaminal lumbar interbody fusion. Spine J. 13(9):1118-25, 2013
                                  3. Du J et al: Early follow-up outcomes after treatment of degenerative disc disease with the discover cervical disc prosthesis. Spine J. 11(4):281-9, 2011
                                  4. Mannion RJ et al: Promoting fusion in minimally invasive lumbar interbody stabilization with low-dose bone morphogenic protein-2--but what is the cost? Spine J. 11(6):527-33, 2011
                                  5. Quan GM et al: Eight-year clinical and radiological follow-up of the Bryan cervical disc arthroplasty. Spine (Phila Pa 1976). 36(8):639-46, 2011
                                  6. Chen NF et al: Symptomatic ectopic bone formation after off-label use of recombinant human bone morphogenetic protein-2 in transforaminal lumbar interbody fusion. J Neurosurg Spine. 12(1):40-6, 2010
                                  7. Coric D et al: Prospective study of cervical arthroplasty in 98 patients involved in 1 of 3 separate investigational device exemption studies from a single investigational site with a minimum 2-year follow-up. Clinical article. J Neurosurg Spine. 13(6):715-21, 2010
                                  8. Kim PD et al: Ectopic bone formation in the pelvis after combined anterior and posterior fusion of the spine with osteogenic protein-1 use: a case report. J Spinal Disord Tech. 23(3):215-20, 2010
                                  9. Ryu KS et al: Radiological changes of the operated and adjacent segments following cervical arthroplasty after a minimum 24-month follow-up: comparison between the Bryan and Prodisc-C devices. J Neurosurg Spine. 13(3):299-307, 2010
                                  10. Suchomel P et al: Clinical results and development of heterotopic ossification in total cervical disc replacement during a 4-year follow-up. Eur Spine J. 19(2):307-15, 2010
                                  11. Traynelis VC: Ectopic bone. J Neurosurg Spine. 12(1):39, 2010
                                  12. Yi S et al: Difference in occurrence of heterotopic ossification according to prosthesis type in the cervical artificial disc replacement. Spine (Phila Pa 1976). 35(16):1556-61, 2010
                                  13. Beaurain J et al: Intermediate clinical and radiological results of cervical TDR (Mobi-C) with up to 2 years of follow-up. Eur Spine J. 18(6):841-50, 2009
                                  14. Geibel PT et al: The use of recombinant human bone morphogenic protein in posterior interbody fusions of the lumbar spine: a clinical series. J Spinal Disord Tech. 22(5):315-20, 2009
                                  15. Kerr EJ et al: Implant design may influence delayed heterotopic ossification after total disk arthroplasty in lumbar spine. Surg Neurol. 72(6):747-51; discussion 751, 2009
                                  16. Wong DA et al: Neurologic impairment from ectopic bone in the lumbar canal: a potential complication of off-label PLIF/TLIF use of bone morphogenetic protein-2 (BMP-2). Spine J. 8(6):1011-8, 2008
                                  17. Joseph V et al: Heterotopic bone formation with the use of rhBMP2 in posterior minimal access interbody fusion: a CT analysis. Spine (Phila Pa 1976). 32(25):2885-90, 2007
                                  18. Mehren C et al: Heterotopic ossification in total cervical artificial disc replacement. Spine (Phila Pa 1976). 31(24):2802-6, 2006
                                  19. Haid RW Jr et al: Posterior lumbar interbody fusion using recombinant human bone morphogenetic protein type 2 with cylindrical interbody cages. Spine J. 4(5):527-38; discussion 538-9, 2004
                                  20. McAfee PC et al: Classification of heterotopic ossification (HO) in artificial disk replacement. J Spinal Disord Tech. 16(4):384-9, 2003
                                  Related Anatomy
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                                  Related Differential Diagnoses
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                                  References
                                  Tables

                                  Tables

                                  KEY FACTS

                                  • Terminology

                                    • Imaging

                                      • Top Differential Diagnoses

                                        • Pathology

                                          • Clinical Issues

                                            • Diagnostic Checklist

                                              TERMINOLOGY

                                              • Abbreviations

                                                • Recombinant human bone morphogenetic protein 2 (rhBMP-2)
                                                • Total disc replacement (TDR)
                                                • Transforaminal lumbar interbody fusion (TLIF)
                                                • Posterior lumbar interbody fusion (PLIF)
                                              • Synonyms

                                                • Heterotopic ossification (HO)
                                                • Ectopic bone formation
                                                • Ectopic ossification
                                                • Extradiscal ossification
                                              • Definitions

                                                • Bone development in an abnormal location
                                                • Occurs in 3 main scenarios
                                                  • Osteobiologic (rhBMP-2) related
                                                  • Total disc replacement (TDR) related
                                                  • Anterior cervical discectomy and fusion (ACDF) adjacent segment related

                                              IMAGING

                                              • General Features

                                                • CT Findings

                                                  • MR Findings

                                                    • Imaging Recommendations

                                                      DIFFERENTIAL DIAGNOSIS

                                                        PATHOLOGY

                                                        • General Features

                                                          • Staging, Grading, & Classification

                                                            CLINICAL ISSUES

                                                            • Presentation

                                                              • Treatment

                                                                DIAGNOSTIC CHECKLIST

                                                                • Consider

                                                                  Selected References

                                                                  1. Simmonds MC et al: Safety and effectiveness of recombinant human bone morphogenetic protein-2 for spinal fusion: a meta-analysis of individual-participant data. Ann Intern Med. 158(12):877-89, 2013
                                                                  2. Singh K et al: Clinical sequelae after rhBMP-2 use in a minimally invasive transforaminal lumbar interbody fusion. Spine J. 13(9):1118-25, 2013
                                                                  3. Du J et al: Early follow-up outcomes after treatment of degenerative disc disease with the discover cervical disc prosthesis. Spine J. 11(4):281-9, 2011
                                                                  4. Mannion RJ et al: Promoting fusion in minimally invasive lumbar interbody stabilization with low-dose bone morphogenic protein-2--but what is the cost? Spine J. 11(6):527-33, 2011
                                                                  5. Quan GM et al: Eight-year clinical and radiological follow-up of the Bryan cervical disc arthroplasty. Spine (Phila Pa 1976). 36(8):639-46, 2011
                                                                  6. Chen NF et al: Symptomatic ectopic bone formation after off-label use of recombinant human bone morphogenetic protein-2 in transforaminal lumbar interbody fusion. J Neurosurg Spine. 12(1):40-6, 2010
                                                                  7. Coric D et al: Prospective study of cervical arthroplasty in 98 patients involved in 1 of 3 separate investigational device exemption studies from a single investigational site with a minimum 2-year follow-up. Clinical article. J Neurosurg Spine. 13(6):715-21, 2010
                                                                  8. Kim PD et al: Ectopic bone formation in the pelvis after combined anterior and posterior fusion of the spine with osteogenic protein-1 use: a case report. J Spinal Disord Tech. 23(3):215-20, 2010
                                                                  9. Ryu KS et al: Radiological changes of the operated and adjacent segments following cervical arthroplasty after a minimum 24-month follow-up: comparison between the Bryan and Prodisc-C devices. J Neurosurg Spine. 13(3):299-307, 2010
                                                                  10. Suchomel P et al: Clinical results and development of heterotopic ossification in total cervical disc replacement during a 4-year follow-up. Eur Spine J. 19(2):307-15, 2010
                                                                  11. Traynelis VC: Ectopic bone. J Neurosurg Spine. 12(1):39, 2010
                                                                  12. Yi S et al: Difference in occurrence of heterotopic ossification according to prosthesis type in the cervical artificial disc replacement. Spine (Phila Pa 1976). 35(16):1556-61, 2010
                                                                  13. Beaurain J et al: Intermediate clinical and radiological results of cervical TDR (Mobi-C) with up to 2 years of follow-up. Eur Spine J. 18(6):841-50, 2009
                                                                  14. Geibel PT et al: The use of recombinant human bone morphogenic protein in posterior interbody fusions of the lumbar spine: a clinical series. J Spinal Disord Tech. 22(5):315-20, 2009
                                                                  15. Kerr EJ et al: Implant design may influence delayed heterotopic ossification after total disk arthroplasty in lumbar spine. Surg Neurol. 72(6):747-51; discussion 751, 2009
                                                                  16. Wong DA et al: Neurologic impairment from ectopic bone in the lumbar canal: a potential complication of off-label PLIF/TLIF use of bone morphogenetic protein-2 (BMP-2). Spine J. 8(6):1011-8, 2008
                                                                  17. Joseph V et al: Heterotopic bone formation with the use of rhBMP2 in posterior minimal access interbody fusion: a CT analysis. Spine (Phila Pa 1976). 32(25):2885-90, 2007
                                                                  18. Mehren C et al: Heterotopic ossification in total cervical artificial disc replacement. Spine (Phila Pa 1976). 31(24):2802-6, 2006
                                                                  19. Haid RW Jr et al: Posterior lumbar interbody fusion using recombinant human bone morphogenetic protein type 2 with cylindrical interbody cages. Spine J. 4(5):527-38; discussion 538-9, 2004
                                                                  20. McAfee PC et al: Classification of heterotopic ossification (HO) in artificial disk replacement. J Spinal Disord Tech. 16(4):384-9, 2003